Background
Methods/Design
Forensic autopsy in Estonia
Study protocol
Pilot study
Main study protocol
Target population
Autopsy process
Information collected at autopsy
General | |
---|---|
Identifiers | study number, forensic autopsy protocol number; |
Time | date and time of death, date and time of autopsy, date and time blood sample taken; |
Macroscopic examination of organs
| |
Heart | weight, length, breadth, depth, thickness of left and right ventricular walls, thickness of intraventricular septum; evidence of acute infarction and/or old infarction, other gross cardiac anomaly, atheromatous occlusion of coronary arteries, appearance of coronary arteries, thrombus of coronary arteries, other cardiovascular system; |
Kidneys | renal disease; |
Lungs | pneumonia, aspiration of gastric contents, active tuberculosis, healed tuberculosis with scarring, other (specify); |
Liver | weight, length, right and left lobe height and depth; fatty liver (focal and diffuse), fibrosis, cirrhosis, other (specify); |
Pancreas | acute and chronic pancreatitis, other (specify); |
Oesophagus, stomach and duodenum | gastritis, gastric ulcer, duodenitis, duodenal ulcer, oesophageal varicosities, oesophagitis, other (specify); |
Brain | weight; haemorrhage, infarction, new contusions, old brain trauma, cortical atrophy, cerebellar atrophy, other (specify); |
Laboratory investigations
| |
Ethanol concentration | alcohol concentration in blood, vitreous humour and urine |
Ethanol biomarkers (subset only) | Phosphatidylethanol (PEth) in blood, ethyl glucronide (EtG) and ethyl sulphate (EtS) in urine |
Other alcohols and ethanol substitutes | methanol, isopropanol, isobutanol, isoamyl alcohol, ethylene glycol in blood and urine; |
Drugs | morphine, fentanyl, marijuana, amphetamine, cocaine, buprenorphine, methadone, other (specify); |
Liver enzymes | gamma-glutamyl transferase (GGT), alanine and aspartine aminotransferase (ALT and AST); |
Histology
| |
Heart | right and left ventriculum and atrium, septum intraventricularis; |
Coronary artery | tissue sample taken in case of thrombosis; |
Liver | right and left lobe; |
Pancreas | parenchyma, any lesion; |
Brain | cortex, cerebellum, basal ganglia, mamiliary bodies; |
Kidneys | right, left; |
Lung | parenchyma, any lesion; |
Stomach and duodenum | lesion; |
Cause of death
| immediate, intermediate, underlying, external, other important diseases, all coded to ICD-10; manner of death. |
Cause of death
Biological samples
Laboratory assays
Interview study
Information collected at interview
General information | Information recorded |
---|---|
Respondent | Age, date of birth, place of birth, nationality, marital status, number of children, education, profession, views about his/her area of residence; |
The deceased and his family at time of death | Composition and structure of household, description of the home of the subject (number of rooms, amenities, properties), economic situation and income of the household, whether/when his parents had died; |
Relationship of res- pondent to deceased | Relationship to the subject, duration and capacity of knowing the subject (special reference of knowing him in the last year before his death); |
Subject | Age, date of birth, place of birth, nationality, marital status, number of children, education, profession, the main reason for ceasing regular paid employment (if applicable); History of serving in the army, serving in a zone of conflict, having been to prison; |
Relations in the family, having close friends, being involved in physical fights during the last year, diseases and disabilities (special reference in the last year before his death), persistent large changes in the subject's circumstances and/or behaviour (diet, exercise, drinking, smoking) that have occurred because of ill health or disability; | |
Duration and pattern of smoking if applicable; | |
Questions regarding drinking of alcohol by the subject
|
Information recorded
|
Frequency and amount of drinking | Frequency and days of week of drinking beer, wine, spirits, surrogates, homemade samogon, alcoholic coctails; Usual and maximum amount of beer, wine, spirits, surrogates, homemade samogon, alcoholic coctails drunk on one occasion (special reference to drinking during the last year before his death); |
Indication of hazardous drinking | Drinking spirits together with either beer or wine at the same sitting, drinking large quantities of spirits without also eating some food at the same sitting, frequency of becoming excessively drunk/having hangover, drinking alcohol before noon, frequency of failing to fulfil his family or personal or work obligations due to drinking alcohol, going to sleep at night with his clothes on because of being drunk, drinking alone, frequency and duration of zapoi, being arrested because he was drunk, drinking surrogates; |
Other alcohol questions | Distance of get to the nearest place where one can buy beverages, being admitted to hospital/clinic because of alcohol poisoning, having had help or advice from a doctor, narcologist, social worker or some other professional for an alcohol problem, subject's father when the subject was growing up or anyone in the subject's household apart from him going on zapoi; |
Surrogates | Main reason and time of start of drinking surrogates, drinking surrogates at home, types and amount of surrogates drunk, subject's father when the subject was growing up or anyone in the subject's household apart from him drinking surrogates; |
Data entry and processing
Statistical analysis
Ethical approval and data protection
Results
Characteristics | Included | Excluded | |||
---|---|---|---|---|---|
Number | % | Number | % |
Pvalue* | |
Age (years)
| 0.416 | ||||
25-34 | 144 | 24.2 | 186 | 26.4 | |
35-44 | 159 | 26.7 | 198 | 28.1 | |
45-54 | 292 | 49.1 | 320 | 45.5 | |
Underlying cause of death**
| 0.001 | ||||
Diseases | 184 | 30.9 | 205 | 29.1 | |
Circulatory system (I00-I99)
| 101
| 54.9
| 103
| 50.2
| |
Digestive system (K00-K99)
| 54
| 29.3
| 63
| 30.7
| 0.591
|
Other diseases
| 29
| 15.8
| 39
| 19.0
| |
Unknown causes (R95-R99) | 16 | 2.7 | 50 | 7.1 | |
External causes (V01-Y98) | 395 | 66.4 | 449 | 63.8 | |
Blood alcohol concentration (BAC)
| 0.013 | ||||
No | 31 | 5.2 | 63 | 8.9 | |
Yes | 564 | 94.8 | 641 | 91.1 | |
BAC < 0.2 mg/g
| 254
| 45.0
| 354
| 55.2
| < 0.001
|
BAC ≥ 0.2 mg/g
| 310
| 55.0
| 287
| 44.8
| |
Total
|
595
|
100
|
704
|
100
|
Cause of death
Cause of death by major groups (ICD-10 code) | Number | % |
---|---|---|
Diseases | 184 | 30.9 |
Circulatory system (I00-I99)
| 101
| 54.9
|
Ischaemic heart diseases (I20-I25) | 42 | 41.6 |
Alcoholic cardiomyopathy (I42.6) | 3 | 3.0 |
Cardiomyopathy (I42, excl I42.6) | 6 | 5.9 |
Cerebrovascular diseases (I60-I69) | 14 | 13.9 |
Other diseases of the circulatory system | 36 | 35.6 |
Digestive system (K00-K99)
| 54
| 29.3
|
Alcoholic liver disease (K70) | 44 | 81.5 |
Cirrhosis and fibrosis (K74) | 1 | 1.9 |
Other diseases of the digestive system | 9 | 16.7 |
Other diseases
| 29
| 15.8
|
Unknown causes (R95-R99)
|
16
|
2.7
|
External causes (V01-Y98)
|
395
|
66.4
|
Transport Accidents (V01-V99) | 38 | 9.6 |
Falls (W00-W19) | 23 | 5.8 |
Accidental drowning and submersion (W65-W74) | 28 | 7.1 |
Inhalation of gastric contents or food causing obstruction | 34 | 8.6 |
of respiratory tract (W78-W79) | ||
Alcohol poisoning (X45) | 45 | 11.4 |
Accidental poisoning by and exposure to noxious | 53 | 13.4 |
substances (X40-X49, excl X45) | ||
Intentional self-harm (X60-X84) | 101 | 25.6 |
Assault (X85-Y09) | 30 | 7.6 |
Exposure to excessive natural cold (X31) | 10 | 2.5 |
Event of undetermined intent (Y10-Y34) | 20 | 5.1 |
Other external causes | 13 | 3.3 |
Total
|
595
|
100
|
Biomarkers
Biomarker, units | Number | % of all autopsies (N = 595) | Median | Range |
---|---|---|---|---|
Ethanol (blood), mg/g | 564 | 94.8 | 0.78 | 0-6.59 |
Ethanol (urine), mg/g | 437 | 73.4 | 1.51 | 0-6.14 |
AST (serum), U/L | 364 | 61.2 | 1014 | 59-28790 |
ALT (serum), U/L | 364 | 61.2 | 792 | 8-42580 |
GGT (serum), U/L | 365 | 61.3 | 92 | 15-1884 |
PEth (blood), μmol/L | 245 | 42.2 | 9.8 | 0-121.5 |
EtG (urine), mg/L | 157 | 26.4 | 79 | 0-2699 |
EtS (urine), mg/L | 157 | 26.4 | 22 | 0-480 |
Proxy informant interviews
Characteristics | Included | Excluded | |||
---|---|---|---|---|---|
Number | % | Number | % |
Pvalue** | |
Age (years)
| 0.291 | ||||
25-34 | 50 | 29.6 | 29 | 27.1 | |
35-44 | 35 | 20.7 | 31 | 29.0 | |
45-54 | 84 | 49.7 | 47 | 43.9 | |
Underlying cause of death
| 0.769 | ||||
Diseases | 70 | 41.4 | 40 | 37.4 | |
Circulatory system (I00-I99)
| 41
| 58.6
| 21
| 52.5
| |
Digestive system (K00-K99)
| 10
| 14.3
| 16
| 40.0
| 0.002
|
Other diseases
| 19
| 27.1
| 3
| 7.5
| |
Unknown causes (R95-R99) | 4 | 2.4 | 2 | 1.9 | |
External causes (V01-Y98) | 95 | 56.2 | 65 | 60.7 | |
Blood alcohol concentration (BAC)
| 0.788 | ||||
measured
| |||||
No | 8 | 4.7 | 5 | 4.7 | |
Yes | 161 | 95.3 | 102 | 95.3 | |
BAC < 0.2 mg/g
| 89
| 55.3
| 49
| 48.0
| < 0.001
|
BAC ≥ 0.2 mg/g
| 72
| 44.7
| 53
| 52.0
| |
Total
|
169
|
100
|
107
|
100
|
Socio-demographic and behavioural characteristics of subjects
Characteristics | Number | % |
---|---|---|
Age group (years) | ||
25-34 | 50 | 29.6 |
35-44 | 35 | 20.7 |
45-54 | 84 | 49.7 |
Nationality
| ||
Estonian | 68 | 40.2 |
Russian | 86 | 50.9 |
Other | 15 | 8.9 |
Marital status before death
| ||
Living with wife in registered marriage | 45 | 26.6 |
Living with partner not in registered marriage | 33 | 19.5 |
Divorced or living separately | 42 | 24.9 |
Widowed | 4 | 2.4 |
Never been married | 45 | 26.6 |
Employment status
| ||
In a regularly paid job | 78 | 46.2 |
In a temporary job | 26 | 15.4 |
Unemployed, looking for job | 23 | 13.6 |
Unemployed, not looking for job | 19 | 11.2 |
Unemployed and disability pension | 12 | 7.1 |
Disability pension (incl 1 retired person) | 11 | 6.5 |
Drank alcohol (of any type including surrogates) several
times or more in the year before death*
| ||
Yes | 142 | 84.0 |
No | 18 | 10.7 |
Do not know | 9 | 5.3 |
Drank alcohol (of any type including surrogates) several
times or more in the month before death *
| ||
Yes | 84 | 53.8 |
No | 45 | 28.8 |
Do not know | 22 | 14.1 |
Missing answer | 5 | 3.2 |
Frequency of drinking any alcohol during last year
| ||
Every day/almost every day | 48 | 28.4 |
1-4 times per week | 47 | 27.8 |
3 times per month or less frequently | 47 | 27.8 |
Never/almost never | 18 | 10.7 |
Do not know | 9 | 5.3 |
Drank surrogates several times or more in the year
before death
| ||
Yes | 18 | 10.7 |
No | 127 | 75.1 |
Do not know | 21 | 12.4 |
Missing answer | 3 | 1.8 |
Smoking status at death
| ||
Smoker | 132 | 78.1 |
Ex-smoker | 15 | 8.9 |
Never smoked | 22 | 13.0 |
Total
|
169
|
100
|
Alcohol biomarkers and proxy reported drinking
Alcohol drinking behaviour of subject before death | Biomarker | |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Ethanol (blood) mg/g | Ethanol (urine) mg/g | AST (serum) U/L | ALT (serum) U/L | GGT (serum) U/L | PEth (blood) μmol/L | EtG (urine)mg/L | EtS (urine) mg/L | |||||||||
N | Median (IQR) | N | Median (IQR) | N | Median (IQR) | N | Median (IQR) | N | Median (IQR) | N | Median (IQR) | N | Median (IQR) | N | Median (IQR) | |
Frequency of drinking any alcohol during last year
| ||||||||||||||||
Every day / almost every day | 45 | 0.63 (0-2.0) | 30 | 0.7 (0-2.9) | 29 | 1558 (562-3210) | 29 | 929 (237-2725) | 29 | 193 (116-526) | 44 | 9.7 (4.1-19.7) | 26 | 78.3 (4.6-179) | 26 | 23.1 (0-439) |
1-4 times per week | 46 | 0 (0-2.1) | 40 | 0.6 (0-3.4) | 30 | 972 (551-1573) | 30 | 985 (355-2618) | 30 | 69 (49-122) | 38 | 8.7 (2.6-16.1) | 33 | 43.4 (4.3-246.9) | 33 | 23.0 (0.09-350) |
3 times per month or more rarely | 45 | 0 (0-2.1) | 37 | 0 (0-2.2) | 33 | 874 (467-2210) | 33 | 910 (258-4675) | 33 | 77 (62-111) | 41 | 5.1 (0.5-19.0) | 31 | 41.7 (0.2-338) | 31 | 8.4 (0-198) |
Never / almost never | 16 | 0 (0-0) | 10 | 0 (0-0) | 11 | 1686 (895-2384) | 11 | 1856 (1393-3319) | 11 | 69 (30-172) | 11 | 0 (0-0.4) | 4 | 0.1 (0-0.2) | 4 | 0.01 (0-0.15) |
P value for trend* | 0.041 | 0.080 | 0.897 | 0.237 | < 0.001 | < 0.001 | 0.046 | 0.038 | ||||||||
Drinking any alcohol during last month
| ||||||||||||||||
Yes | 80 | 0.2 (0-2.2) | 58 | 0.6 (0-3.4) | 54 | 1114 (634-3119) | 54 | 988 (466-2940) | 54 | 92 (57-168) | 66 | 10.8 (4.3-22.9) | 49 | 94.6 (4.6-338) | 49 | 23.0 (1.1-69) |
No | 44 | 0 (0-2.0) | 34 | 0 (0-2.2) | 26 | 896 (399-1779) | 26 | 885 (174-2725) | 26 | 96 (66-172) | 41 | 3.9 (0.2-10.3) | 29 | 37.3 (0.3-172.2) | 29 | 8.4 (0.1-49.8) |
P value** | 0.675 | 0.373 | 0.166 | 0.399 | 0.962 | 0.001 | 0.180 | 0.224 | ||||||||
Drinking surrogates during last year
| ||||||||||||||||
Yes | 16 | 0.3 (0-1.8) | 11 | 0 (0-3.1) | 11 | 1558 (283-6208) | 11 | 1031 (237-1951) | 11 | 255 (86-511) | 16 | 9.7 (3.4-18.5) | 10 | 138.5 (2.7-771) | 10 | 33.3 (0.6-98.7) |
No | 12 1 | 0 (0-2.1) | 95 | 0 (0-2.9) | 83 | 1036 (553-2604) | 83 | 1078 (359-3810) | 83 | 85 (52-163) | 103 | 6.7 (1.2-15.5) | 74 | 51.9 (2.5-246.9) | 74 | 12.6 (0.7-53.7) |
P value** | 0.912 | 0.553 | 0.922 | 0.202 | 0.010 | 0.362 | 0.349 | 0.355 |